Management of Older Patients With NSTE-ACS

Nov 16, 2023
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Authors:
Berg ES, Tegn NK, Abdelnoor M, et al., on behalf of the After Eighty Study Investigators.
Citation:
Long-Term Outcomes of Invasive vs Conservative Strategies for Older Patients With Non–ST-Segment Elevation Acute Coronary Syndromes. J Am Coll Cardiol 2023;82:2021-2030.
Summary By:
Bina Ahmed, MD, FACC

Quick Takes

  • Among older patients (≥80 years) with NSTE-ACS, an invasive management strategy plus optimal medical therapy was superior to a conservative strategy on long-term follow-up.
  • Patients who underwent invasive management had a substantial gain in event-free survival at 5 and 10 years (276 and 337 days) mainly driven by a lower incidence of MI and need for revascularization.
  • The benefit of invasive management was more pronounced among the higher-risk cohort of patients with renal failure and diabetes.

Study Questions:

What are the long-term clinical outcomes of invasive versus conservative management strategies among patients aged ≥80 years presenting with non–ST-segment elevation acute coronary syndrome (NSTE-ACS)?

Methods:

The After Eighty Study randomized 457 patients with NSTE-ACS between 2010–2014 to an invasive strategy involving early coronary angiography with immediate evaluation for revascularization and optimal medical therapy (OMT) or to a conservative strategy (OMT only). The primary endpoint was a composite of myocardial infarction (MI), need for urgent revascularization, stroke, and death. The current analysis presents data evaluating long-term outcomes.

Results:

After a median follow-up of 5.3 years, the invasive strategy was superior to the conservative strategy in the reduction of the primary endpoint (incidence rate ratio, 0.76; 95% confidence interval [CI], 0.63-0.93; p = 0.0057). The invasive strategy demonstrated a significant gain in event-free survival of 276 days (95% CI, 151-400 days; p = 0.0001) at 5 years and 337 days (95% CI, 123-550 days; p = 0.0001) at 10 years. These results were consistent across subgroups of patients with respect to major cardiovascular prognostic factors.

Conclusions:

In patients aged ≥80 years with NSTE-ACS, the invasive strategy was superior to the conservative strategy in the reduction of composite events and demonstrated a significant gain in event-free survival.

Perspective:

Among older patients (aged ≥80 years) with NSTE-ACS, an invasive management strategy plus OMT was superior to a conservative strategy on long-term follow-up. Patients who underwent invasive management had substantial gain in event-free survival at 5 and 10 years (276 and 337 days) mainly driven by a lower incidence of MI and need for revascularization. Overall mortality in this cohort was 87% during long-term follow-up. The benefit of invasive therapies was more pronounced among the higher-risk cohort of patients with renal failure and diabetes. In addition, women represented nearly 50% of the enrolled patient cohort and despite having less obstructive coronary artery disease, benefits of invasive therapy were comparable between men and women. Despite these findings, management of this high-risk group of patients should still be individualized, taking into account factors such as frailty, dementia, and life expectancy.

Clinical Topics: Acute Coronary Syndromes, Cardiovascular Care Team, Geriatric Cardiology, Stable Ischemic Heart Disease, Vascular Medicine, Chronic Angina, Interventions and ACS

Keywords: Acute Coronary Syndrome, Geriatrics, Non-ST Elevated Myocardial Infarction


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